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Insurer License Application Form. This is a New Jersey form and can be use in Motor Vehicle Commission Statewide.
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Tags: Insurer License Application, New Jersey Statewide, Motor Vehicle Commission
New Jersey
Motor Vehicle Commission
Dealer Section
P.O. Box 171
Trenton, New Jersey 08666-0171
PO Box 171
Dealer Section
Enclosed is copy of the applicable law, application and supplemental forms
necessary to apply for Insurer license plates and registrations.
Each applicant for Insurer Iicense plates and registrations must establish and
maintain a permanent place of business in New Jersey. Said business must
display an exterior sign, which reflects the business name and the facility must
conform with all municipal requirements.
The fee for issuance of the registrations and plates is $257.50 for one (1) set and
is to be paid by certified check or money order. In addition, a certificate of
insurance must be submitted which reflects liability insurance coverage in the
minimum amounts of amount of $100,000 per person/incident up to $250,000 per
incident for bodily injury or death, $25,000 per incident for property damage and
$250,000 combined personal injury and property damage per incident covering
all dealer plates. The certificate holder must read as follows:
NJ Motor Vehicle Commission
Business License Services - Dealers
PO Box 171
Trenton, NJ 08666
If you have any questions, please call (609) 292-4517.
Sincerely,
Business License Services
(Rev01/07)
On the Road to Excellence
www.njmvc.gov
New Jersey is an Equal Opportunity Employer
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Business License Services
PO Box 171
Trenton, New Jersey 08666-0171
Motor Vehicle
Commission
APPLICATION FOR LICENSE
FOR OFFICE USE ONLY
License No.
Date
Reg. No.
Email
Approved by
The undersigned hereby applies for the license(s) checked in Part 3 and submits the following certified statement:
Corp Code
1.
Business phone
Name of Business (if corporation, corporate name)
____________________________________________________________________
Trade Name
2. Please Check
[ ] Corporation
Street Address
[ ] Other
Zip Code
City
County
All applicants please provide the following information and attach copies
of proof thereof:
A. NJ Sales Tax Identification Number
B. NJ Unemployment Registration Number
C. Federal Employer Identification Number
4.
Complete the following for proprietor, partners, or corporate officers:
Title
Name
5.
3. Please Check appropriate Box for License:
[
[
[
[
[
[
] Leasing Company
] Driving School
] Moped Dealer
] Junkyard
] Private Inspection Facility
] Fleet Fleet Inspection Facility
[ $ ] Other
Home Address
[
[
[
[
[
] New & Used Motor Vehicle Dealer
] Auto Body Repair Facility
] Used Motor Vehicle Dealer
] Fleet DEIC
] DElC
Insurer
Telephone Number
Have the owners, partners, or officers ever been arrested, charged or convicted of a criminal or disorderly persons offense in this or any other state?
[ ]Yes
[ ]N o
6
[ ]Proprietorship
[ ] Partnership
if yes, explain:
Do you knowingly intend to employ a person who has been convlcted of the above, or any other crime or who was previously licensed as any
in this or any other state and was subject to license suspension or revocation?
Of
the above
[ ]Yes
[ ]No
7
Give name and address of person
Have the owners, partners or corporate officers ever held any of the above licenses?
[ ] Yes
[ ]N o
If yes, please explain the type of license and license numbers
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8.
Was the license ever suspended or revoked?
[ ]Yes
[ ]N o
If yes, explain:
Have the owners, partners or corporate officers, agents or employees of your organization ever used an alias or been known by any other name
9.
[ ]Yes
If yes, explain:
[ ]N o
10.
Does any stockholder own more than 10% of the corporation's stock?
If yes, give name, address and holding
[ ] Yes
[ ]N o
11
Attach copy of the Certificate of Incorporation/Formation which has
been filed with the N.J. Secretary of State. Foreign Corporations must
submit a copy of their Authorization to do business in New Jersey as
a Foreign Corporation in addition to a copy of their corporate/formation
papers.
Place of Incorporation/Formation
Date of Incorporation/Formation
Date of authorization to do business in New Jersey
12
The applicant certifies all information contained herein is true and agrees any untruthful representation and any violation of the applicable statutes and regulations
promulgated by the Commission shall be reasonable and proper grounds for license suspension or revocation. He further agrees to notify the Commission
immediately of any change in the status of the business or of any other information which would change the answers and statements in this application or
supplement thereto.
13
The individual(s) signing this application certify that they have read the applicable statutes and are thoroughly familiar with the details and penalties provided.
I, the undersigned, hereby certify that I _________________of the above business previously named____________________________________________
Owner, Partner, Officer, Member
and that the information I have submitted is true to the best of my knowledge.
_______________________________________________________________
Print Name of Applicant
Signature and Title of Applicant
the undersigned, hereby certify that I am Secretary/Member/Partner of the above Corporation and have witnessed the signature of__________________________
who is
of said corporation.
President, Vice-President or Member
Signatureof Secretary/Member/Partner
APPROVAL CERTIFICATE
Clerk of the Municipality of
County of
(Print Name)
State of New Jersey, hereby certify that the Municipal Governing Body or Zoning Commission has approved
the location. establishment and maintenance of the business checked below:
[ ] Leasing Company
[ ] Fleet DElC
[ ] Driving School
[ ] New & Used Motor Vehicle Dealer
[ ] Moped Dealer
[ ] Auto Body Repair Facility
[ $ ] Other Insurer
[ ] Junkyard
[ ] Private Inspection Facility
[ ] Used Motor Vehicle Dealer
[ ] Fleet Inspection Facility
[ ] DElC
located at
Complete Address
_____________________________________________________
Print Name of Municipal or Zoning Board Clerk
BLC-183 (R12/04)
Signature of Municipal or Zoning Board Clerk
Date
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BUSINESS LICENSE SERVICES
SUPPLEMENTARY APPLICATION
BUSINESS NAME
BUSINESS PHONE #
1. FULL NAME INCLUDING MIDDLE NAME AND SUFFIX, IF ANY
2. STREET ADDRESS
CITY
STATE
HOME PHONE #
3. HOW LONG HAVE YOU LIVED AT THE ABOVE ADDRESS?
4. LIST THE CITIES, STATES OR FOREIGN COUNTRIES WHERE YOU LIVED BEFORE AND HOW LONG YOU W E R E IN EACH STATE OR COUNTRY.
5. DATE OF BIRTH (MO. DAY, YEAR)
7. SEX
6. PLACE OF BIRTH: (CITY, STATE OR FOREIGN COUNTRY)
8. HEIGHT
11. SOCIAL SECURITY NUMBER
10. COLOR OF EYES
9. WEIGHT
12. DRIVER LICENSE NUMBER (STATE)
13. HAVE YOU, IN THIS OR ANY OTHER STATE OR COUNTRY EVER BEEN ARRESTED, CHARGED OR CONVICTED OF A CRIME, DISORDERLY PERSONS OFFENSE,
VIOLATION OF CONSUMER PROTECTION LAWS OR REGULATIONS?
YES
NO
IF YES, ATTACH EXPLANATION DESCRIBING NATURE OF OFFENSE, DATE, CITY AND STATE WHERE OFFENSE OCCURRED, IDENTIFY COURT OR ADMINISTRATIVE
TRIBUNAL BEFORE THE CASE WAS TRIED, DATE AND SENTENCE.
14.
I CERTIFY THAT THE INFORMATION PROVIDED HEREIN AND ATTACHMENTS, IF ANY, IS TRUE AND COMPLETE TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
SIGNATURE:
DATE
1. FULL NAME INCLUDING MIDDLE NAME AND SUFFIX. IF ANY
2. STREET ADDRESS
CITY
STATE
3. HOW LONG HAVE YOU LIVED AT THE ABOVE ADDRESS?
HOME PHONE #
4. LIST THE CITIES, STATES OR FOREIGN COUNTRIES WHERE YOU LIVED BEFORE AND HOW LONG YOU WERE IN EACH STATE OR COUNTRY.
5 DATE OF BIRTH (MO. DAY, YEAR)
7. SEX
11. SOCIAL SECURITY NUMBER
6. PLACE OF BIRTH: (CITY. STATE OR FOREIGN COUNTRY)
8. HEIGHT
9. WEIGHT
10. COLOR OF EYES
12. DRIVER LICENSE NUMBER (STATE)
13. HAVE YOU, IN THIS OR ANY OTHER STATE OR COUNTRY EVER BEEN ARRESTED, CHARGED OR CONVICTED OF A CRIME, DISORDERLY PERSONS OFFENSE,
VIOLATION OF CONSUMER PROTECTION LAWS OR REGULATIONS?
YES
NO
IF YES, ATTACH EXPLANATIONDESCRIBING NATURE OF OFFENSE, DATE, CITY AND STATE WHERE OFFENSE OCCURRED, IDENTIFY COURT OR ADMINISTRATIVE
TRIBUNAL BEFORE THE CASE WAS TRIED, DATE AND SENTENCE.
14. I CERTIFY THAT THE INFORMATION PROVIDED HEREIN AND ATTACHMENTS, IF ANY, IS TRUE AND COMPLETE TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
SIGNATURE:
BLC-205B (R12/03)
DATE
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39:3-18. General registration; "D" or temporary plates; fees
A manufacturer of motor vehicles, motor-drawn vehicles, motor vehicle bodies, motorized
bicycles, or motorcycles doing business in this State may, with regard to motor or motor-drawn
vehicles, motorized bicycles, or motorcycles owned or controlled by him, obtain general
registration and registration plates therefor of the style and kind provided for in this subtitle, with
the letter “D” stated thereon. Such plates can be placed on any vehicle or cycle owned or
controlled by such manufacturer, but only if it is operated only for shop, demonstration or
delivery purposes.
A bona fide converter of commercial motor vehicles, motor-drawn vehicles or motor vehicle
chassis doing business in this State may, with regard to motor or motor-drawn vehicles owned or
controlled by him, obtain general registration and registration plates therefor of the style and kind
provided for in this subtitle, with the letter “D” stated thereon. Such plates can be placed on any
vehicles owned or controlled by such converter, but only if such vehicles are operated for shop,
demonstration or delivery purposes.
A bona fide dealer in motor vehicles, motor-drawn vehicles or motorcycles doing business in this
State and having a license to do business as such issued by the director may, with regard to motor
or motor-drawn vehicles or cycles owned by him, obtain general registration and registration
plates therefor of the style and kind provided for in this subtitle, with the letter “D” stated
thereon. Such plates shall only be placed on any vehicle or cycle owned by such dealer; and
provided, such vehicle is not used for hire. Any person who shall be convicted of a violation of
this paragraph shall be subject to a fine not, exceeding $100.00.
A bona fide dealer in motorized bicycles, as defined in R.S. 39:1-1, who has an established place
of business in this State, may, with regard; to motorized bicycles owned by him, obtain general
registration and registration plates therefor of the style and kind provided for in this subtitle, with
the letter “D” stated thereon. The plates can be placed on a motorized bicycle by the dealer, but
only if the motorized bicycle is operated only for shop, demonstration, or delivery purposes.
Any person engaged in the business of financing the purchase of motor or motor-drawn vehicles
or motorized bicycles or lending money thereon may, with regard to motor or motor-drawn
vehicles or motorized bicycles owned or controlled by him, obtain general registration and
registration plates therefor of the style and kind provided for in this subtitle, with the word
“temporary” stated thereon. Such plates can be placed on any such vehicle only when it is being
transported from the place where it has been kept by the purchaser or borrower to the place where
it is to be kept by the repossess or, when the repossessor desires to operate it for the purpose of
demonstration for sale.
Any corporation engaged in the business of insuring motor vehicles, motorized bicycles, or
motor-drawn vehicles against theft may, with regard to vehicles owned or controlled by it, obtain
general registration and registration plates therefor of the style and kind provided for in this
subtitle, with the word “temporary” stated thereon. Such plates can be placed on any such vehicle,
if ownership or control thereof has been obtained by virtue of the terms of an insurance against
theft contract made by such corporation, and only "when the vehicle is to be transported for
delivery to the owner thereof from the place where it has been abandoned by or seized from a
thief.
Any person, partnership or corporation engaged in the business of transporting motor or motordrawn vehicles or motorized bicycles from the place of manufacture for delivery to dealers may,
with regard to such vehicles, obtain general registration and registration plates therefor of the
kind and style provided for in this subtitle, with the word “temporary” stated thereon, but only if
the director is satisfied as to the financial responsibility of such person, partnership or corporation
to meet any claim for damages arising out of any automobile accident and satisfactory evidence
of such responsibility ;has been filed with him.
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Any person engaged in the business of renting or leasing motor vehicles, motorized bicycles, or
motor-drawn vehicles may, with regard to said motor vehicles, motorized bicycles, or motordrawn vehicles owned by him, obtain general registration and registration plates therefor,
provided for in this subtitle, with the word “temporary” stated thereon. Said registration plates
may be placed on any motor vehicle, motorized bicycle, or motor-drawn vehicle owned by such
person while said vehicle is not individually registered and not in use as a rented or leased
vehicle.
A bona fide dealer in “nonconventional” type motor vehicles, as defined in R.S. 39:10-2, who has
an established place of business in this State, may, with regard to “nonconventional” type motor
vehicles owned by him, obtain general registration and registration plates therefor of the style and
kind provided for in this subtitle, with the letter “D” stated thereon. Such plates can be placed on
any “nonconventional” type motor vehicle by such dealer, but only if such "nonconventional"
type motor vehicle is operated only for shop, demonstration or delivery purposes.
Any person, partnership or corporation engaged in the business of conducting a wholesale
automobile auction block in this State for duly licensed dealers only, at least once each week,
may, with regard to vehicles controlled by it, obtain general registration and registration plates
therefor of the style and kind provided for in this subtitle, with the word "temporary" stated
thereon. Such plates can be placed on any vehicle controlled by the auction block, which is to be
transported from the place where stored by the owner to the auction block. Such plates may not
be displayed on a vehicle sold at the auction block for delivery to the purchaser. Application for
such plates shall be approved only if the director is satisfied as to the financial responsibility of
such person, partnership or corporation to
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